Household Insurance Quote NAME PROPOSER sex Male   Female Date of Birth: Address Post Code eMail Telephone Mobile Person to contact Best time for contact? Employment status   Employee Company Director Disability Employed Household Duties Independent Means Retired Self Employed Student Unemployed Voluntary Work Occupation   Type of insurance   House Insurance House & Contents Insurance Contents Insurance only NAME (SPOUSE/PARTNER)   sex   Male   Female Date of Birth:   Address     Post Code   eMail   Telephone   Mobile   Person to contact   Best time for contact?   Employment status   Employee Company Director Disability Employed Household Duties Independent Means Retired Self Employed Student Unemployed Voluntary Work Occupation   Year property was built   Type of property   Detached Semi-detached Bungalow Flat If Flat, state which floor:   Type of construction: (eg. brick / stone / tiled)   Buildings sum insured   Contents sum insured   Is Accidental Damage cover required on either?   Yes No Is All Risks cover required for possessions away from home?   Yes No If Yes, to what value? Do you have any specified Items of high value? (e.g. collections / art /jewellery) Yes No If Yes, to what value?         Previous insurance history and no-claims discount:         Details, including costs, of all claims in last 5 years:         Is the property free from signs of subsidence/ground heave?   Yes No Is the property situated in a Flood Risk Area?   Yes No If Yes, how far (metres) from the nearest river/water course, etc.?   Is the property fitted with 5-lever mortise deadlocks on all final exit doors?   Yes No Are all accessible windows fitted with key-operated locks?   Yes No Is the property fitted with an intruder alarm?   Yes No If Yes, pleae state which system:   Is the property Grade 1 or 2 listed?   Yes No       Comments   WHITE KNIGHT GROUP Britannia House High Street Bream, Lydney Glos GL15 6JS Tel 01594 563288 Fax 01594 564084 Email janeclark@whiteknightgroup.co.uk FSA number is 121356 White Knight Group is an independent intermediary authorised and regulated by The Financial Services Authority who also trade under the names of Dean Magna Insurance & Financial Consultants, Farmer & Clark Insurance & Financial Consultants and Swambo Woollett Insurance & Financial Consultants. Please refer to www.fsa.gov.uk for further information.

Data Protection Any personal or financial information supplied to The Group may be stored, used and transmitted to Insurers,Brokers,credit Reference Agencies and Financial Services Institutions in the context of advising/making recommendations on, and arranging transactions and related credit facilities in, General Insurance business on your behalf. Insurers share information with each other via the “Claims and Underwriting Exchange Register” and the “Motor Insurance Anti-fraud and Theft Register” to aid the prevention of fraudulent claims. Disclosure of Material Facts Please advise White Knight Group immediately if any information contained herein is incorrect. This Statement of Fact forms the basis of the Insurance contract. A Material Fact is one likely to influence an Insurer in the assessment and acceptance of the Insurance. All material facts known to you should be disclosed. Should you be in doubt whether or not a fact is material, it should be disclosed for your own protection, since failure to disclose a material fact may invalidate the Policy.

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